the thoughts of a surgeon in the notorious province of mpumalanga, south africa. comments on the private and state sector. but mostly my personal journey through surgery.

Saturday, July 26, 2008

buff and turf

the other day i read a post about the age old medical practice of the buff and turf. bearing in mind i also recently posted about icu, i was reminded of one of the worst turfs i ever saw.

it was during my icu rotation. we were on morning rounds with the consultant when a medical technologist came running in."there is a major disaster in casualties. can someone please come as fast as possible to help?"naturally we all rushed over there. we were not prepared for what we saw.

in resus was a patient in severe shock. he was extremely pale and had almost no blood pressure. his abdomen was severely distended and sported a midline scar which had been crudely closed with a running nylon suture. the picture that is forever impregnated into my mind is the blood squirting out between the sutures. there were multiple streams of blood literally shooting up in a neat little line. as the patient rolled from side to side it reminded me of the sprinkler my parents had when i was a child. each line seemed to arch elegantly one way and as he rolled the other way, these fountains seemed to slowly follow. it may even have been beautiful in a sense if the setting was not so dire.

we jumped to work. one started cpr (it was needed) while another threw a high flow line into his subclavian vein (we used a schwann sheath). the third made some desperate, probably futile attempt to apply direct pressure to the abdomen. it seemed like a good idea at the time. during all this action we not so quietly and much less subtly enquired where the patient came from and why the surgeon on call wasn't waiting in casualties when he arrived. everyone pled ignorance. it seemed the patient arrived from a peripheral hospital without there being any warning that he was coming. with all the action that was all we discovered about his history then. our energies were concentrated on getting him to theater which we pretty quickly did. being the icu team, we then handed over to the guys in general surgery.

later we heard his story. the patient had been shot through the abdomen. at the hospital he presented to he was taken to theater. there the medical officer who operated him started by repairing all the bowel injuries. thereafter he decided to explore the retroperitonealhaematoma. as it turned out this action would reveal that the bullet had gone straight through the ivc.

i can just imagine his thought process. just before 'oh sh!t!!!' he probably thought 'i wonder what i'll find under here?' together with the 'oh sh!t!!!' which had no doubt evolved to 'oh f#@k!!!' he probably thought 'help!!!'. with this he decided to pack the abdomen and post the patient to anywhere away from where he was. we were that anywhere. in his raw panic he neglected to phone ahead and give any form of warning that this disaster was turfed to us.

truth be told i feel for the medical officer thrown into situations he is ill equipped to handle. but i find his overall actions difficult to justify. i think the reason he didn't phone is that he was afraid the academic hospital wouldn't accept a patient in mid operation for an ivc injury (his best chance which was slim under the circumstances was the operation he was undergoing at the time) and the rattled doctor wasn't willing to take that chance. all he knew is he wanted that patient far away from him and nothing was going to get in the way of that.

p.s the patient actually survived his operation and only died shortly after. well done to the operative team.

I like the sprinkler imagery too. I used to think the spurting arc of bright red arterial blood from the end of a Seldinger needle was beautiful. Of course, that is the only place I've seen the 'sprinkler' and I don't want to see it anywhere else.

greg, the point is that he wasn't a surgeon. he was just a medical officer in a peripheral hospital, maybe only a few years out of medical school. he was in a situation he was not equipped to handle. in a sense he did what he thought was right. i don't think he did the right thing for the record, but the post was actually more about that he dumped the problem on us and was too scared of our possible response to let us know the patient was coming

We have a significant share of buff and turf cases too. In our case it is usually just turf, as there is no buffing at all. Usually they are from a local community neurosurgeon who is miraculously "busy operating" every time a patient without insurance shows up at the hospital he covers. Those turn out to be "great university cases" and end up on our doorstep.

Am I wrong, or should one not open a retropertoneal hematoma unless the patient is obviously tanking? (And you have the tools and talent to handle what you might find there....)Imagine the horror and panic of the medical officer! I guess he probably would have done a better job of packing (the abdomen, not his belongings)if he wasn't so terrified for himself and the patient.The sprinkler imagery is perfect. I love these type of stories, gets my adrenaline going just reading about it.

buckeye, we generally leave the lateral ones alone if they are not pulsatile or expanding. to open them invariably ends in a nefrectomy. pelvic with the presacral plexus is another monster all together.

not really suck a good save seeing that the patient died in the end anyway.

Oops...your fine print at the end must have been just a little too fine....thought I read he lived.

This is from Feliciano:The management of retroperitoneal hematomas remains confusing to many surgeons because the available literature frequently groups patients with blunt and penetrating etiologies together. Because the underlying injuries and their treatment may differ considerably, the nonoperative or operative approach to the common hematomas is based on mechanism of injury coupled with hemodynamic status of the patient and extent of associated injuries. After blunt trauma, selected retroperitoneal hematomas in the lateral perirenal and pelvic areas do not require operation and should not be opened if discovered at operation. Midline, lateral paraduodenal, lateral pericolonic not associated with pelvic, and portal hematomas are opened after proximal vascular control has been obtained, if appropriate. Retrohepatic hematomas without obvious active hemorrhage are not opened. After penetrating trauma, most retroperitoneal hematomas are still opened. Exceptions include isolated lateral perirenal hematomas that have been carefully staged by CT and some lateral pericolonic hematomas. As with blunt trauma, retrohepatic hematomas without obvious active hemorrhage are not opened.

buckeye, thanks for the reference. i think the perirenal penetrating wound section may be a bit old. although these days one goes to theater with a pretty good ct idea of the extent of kidney injuries, so that escape clause in the article makes it still valid. still, pretty much only a vascular pedicle injury or uncontrolled bleeding (same thing??) warrant nefrectomy. i've left some nearly macerated kidneys (handgun injuries) in and they surprisingly look good on a contrast scan a good few months down the line. but these days, armed with the scan, one would know preoperatively that you're not going to open the kidney's faccia (which equals nefrectomy)

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the aim of this blog is to give insight into the mind of a particular surgeon, me. although every story is loosely based on fact, patients have been changed suitably to protect their identity. the opinions expressed are mine alone and are not meant to be considered medical advice or the opinion of any institution.